DSI - Developmental Services, Inc.

*To print an application select either link: English or Español

Instructions for Applicant
Thank you for applying to Developmental Services, Inc. Please take time to carefully complete this application. When completing the application, please follow these procedures:

1 . Please complete all appropriate sections of the application and answer all questions. (This is extremely important in the hiring process).

2. A resume may not be submitted in place of the application. Should you choose to submit a resume with your application, it will be forwarded to the hiring department along with your application.

3. Your application remains on file for 12 months.

Name:

(Last)

(First)

(Middle)

Present Address:

(Street)

(City)

(State)

(Zip)

If At Present Address Less Than 3 Years Complete The Following:

(Street)

(City)

(State)

(Zip)

(County)

(Street)

(City)

(State)

(Zip)

(County)

Phone Number:

Social Security Number:

Position(s) Applied For:
Location(s) Applied For:

Have you ever been employed by us before?		Yes No
If yes, give:	(Date)	(Title)	(Location)
	(Name)

Have you been convicted of a felony?

Yes

If yes, specify charges that resulted in conviction(s):

(*convictions will not necessarily disqualify an applicant)

EDUCATION

Enter highest grade completed:
Do you have a High School Diploma?	Yes
Do you have a General Educational Development (GED)?	Yes

List any additional education:
	Name & Location of Institution	Years Completed	Degree/Certificate
1.
2.
3.

On what date will you be available for work?

Can you work:

Weekends
Evenings
Nights

Are you available to work:			Full-Time Part-Time Temporary

Will you work overtime when necessary?			Yes No

Do you have your own transportation if necessary?			Yes No

SPECIAL JOB-RELATED SKILLS AND QUALIFICATIONS

Can you speak any foreign languages?	Yes	Which?
Do you have any military training?	Yes	Type
Do you have any special license/certifications?	Yes	Type
Do you have any specialized training?	Yes	Type
Please list any volunteer activities or any honors you have received.

Work History

Describe your work experiences, beginning with your most recent job.

Employer:
Address:
Supervisor's Name:
Phone Number:
Date Employed:	(From)	(To)
Job Title & Duties:
Reason for Leaving:

Employer:
Address:
Supervisor's Name:
Phone Number:
Date Employed:	(From)	(To)
Job Title & Duties:
Reason for Leaving:

Employer:
Address:
Supervisor's Name:
Phone Number:
Date Employed:	(From)	(To)
Job Title & Duties:
Reason for Leaving:

References

Give name, address, and telephone number of 3 references who are not related to you and are not previous employers, but are aware of your work history:

1. Name:	Address:	Telephone:
2. Name:	Address:	Telephone:
3. Name:	Address:	Telephone:

Applicant's Statement

I certify that answers given herein are true and complete to the best of my knowledge and that I am legally authorized to work in the U.S.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision, including contacting previous employers and references. I understand that a search of my driving record and criminal history will be conducted prior to my employment. I understand that employment may be conditioned upon the results of these verifications.

This application for employment will remain on file for 12 months. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the employee may resign at any time and the employer may discharge the employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Equal Opportunity / Affirmative Action Statistics

Developmental Services, Inc. is an equal opportunity affirmative action employer. The Government requires us to collect and report certain census information. The information (asked for below) will be used only in statistical reports we are required to submit to the Federal Government. This form will be separated from the application immediately upon receipt at Developmental Services, Inc.

Title of position applied for:
Date of application:
Birthdate:
Do you have a disability?	Yes	No

Sex / Race - Ethnicity of Applicant

	Male	Female
Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
American Indian or Alaskan Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or Community attachment.
Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.

AUTHORIZATION TO RELEASE INFORMATION
I HEREBY AUTHORIZE THE INDIANA BUREAU OF M0TOR VEHICLES TO RELEASE ANY AND ALL INFORMATION ON FILE REGARDING:
(Name)	(Maiden Name)	(Date of Birth)
(Driver's License Number)	(License Classification: Operator, Chauffer, PPC, CDL Class)
(Signature)	(Social Security Number)

MY PERSONAL VEHICLE INSURANCE COVERAGE IS WITH:
(Name of Company)	(Date Coverage Expires)
(Policy Number)

In addition, I authorize Developmental Services, Inc. to request a Limited Adult Criminal History.
(Name)
(Supervisor's Name)	(Date)	(Cost Center #)

Signature
Date